Birkwood Village Of Fort Madison
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Madison, Iowa.
- Location
- 1702 41st Street, Fort Madison, Iowa 52627
- CMS Provider Number
- 165227
- Inspections on file
- 21
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Birkwood Village Of Fort Madison during CMS and state inspections, most recent first.
A resident with an indwelling catheter, bowel incontinence, a Stage IV sacrococcygeal pressure ulcer, additional deep tissue injuries, and moisture-related rashes under the breasts and in the peri area required multiple ordered treatments, including wound cleansing and dressing, antifungal cream, and nephrostomy tube site care. During an observed care episode, an RN repeatedly changed gloves between cleaning bowel, performing coccyx wound care, applying topical treatments to the thigh, breast, and groin, and completing nephrostomy tube site care, but did not perform hand hygiene between glove changes, contrary to the facility’s hand hygiene policy requiring hand hygiene before donning and after removing gloves.
Surveyors identified failures in food labeling, storage, and sanitation, including opened containers of tuna and chicken salad kept beyond the facility's five-day limit, dust accumulation on the ice machine filter, improper storage of a styrofoam scoop in a sugar bin, and a dietary staff member preparing pureed food without a beard restraint.
Two residents were not provided with the required NOMNC (CMS-10123) when their Medicare Part A skilled services ended after meeting therapy goals. Instead, only the SNF ABN (Form 10055) was issued, due to staff confusion and lack of proper training on notification requirements. The facility also lacked a policy for beneficiary notifications.
A resident with severe cognitive impairment and multiple mental health diagnoses did not have their care plan updated to include required PASRR Level II specialized services, such as psychiatric medication management and supportive counseling. Staff interviews confirmed that these services were not initiated and the care plan lacked necessary interventions.
A resident with diagnoses of Parkinsonism, depression, and PTSD had a care plan that did not specify the reasons or triggers for PTSD, despite being cognitively intact and receiving medication for the condition. Staff interviews revealed a lack of knowledge about the resident's PTSD triggers, and the care plan only included general interventions without individualized details.
A resident with a history of constipation, diabetes, and end stage renal disease experienced multiple episodes of no bowel movement for several days, during which PRN medications were not consistently administered and staff responses varied. The facility did not have a formal bowel management protocol, leading to delays in intervention and inconsistent care for constipation.
Nursing staff responsible for wound care and wound VAC application for a resident with complex medical needs did not have formal training or competency verification. The LPN performing these tasks relied on self-directed learning, and facility leadership confirmed there was no designated, formally trained wound care nurse or policy for wound care or wound VAC use.
Two residents with diabetes received insulin injections despite physician orders to hold the medication if blood sugar was less than 150. Nursing staff administered insulin on multiple occasions when blood sugar readings were below the specified threshold, and staff interviews revealed confusion or disregard for the prescribed parameters. The facility lacked a policy to guide medication administration in these cases.
A resident experienced severe complications due to improper catheter management at a facility. After a routine catheter change, the resident had little to no urine output and bloody urine for several days. The facility failed to promptly address these symptoms, leading to a hospital diagnosis of emphysematous cystitis, acute kidney injury, and right lower lobe pneumonia. The catheter balloon was found to be incorrectly placed in the urethra, causing trauma and a UTI.
The facility failed to maintain adequate food temperatures, as observed during a survey. A resident expressed dissatisfaction with the food's taste, temperature, and appearance. Staff recorded food temperatures below the facility's policy requirements, and interviews revealed inconsistencies in understanding the required temperatures. The Dietary Manager confirmed that some food items were served below the expected temperature.
A facility failed to maintain proper infection control during medication administration when an LPN handled medications with bare hands. The LPN was observed touching Levitracetam, Pregabalin, and Calcium with Vitamin D3 tablets directly while preparing them for a resident. The Infection Preventionist and DON acknowledged the issue, but the facility's policy did not address this concern.
A resident with intact cognition reported being treated in an undignified manner by a CNA, who made derogatory comments about the resident's personal life and incontinence. The CNA refused to provide care and turned off the resident's call light, leading to feelings of intimidation and verbal abuse. The facility's investigation substantiated the abuse allegations, resulting in the CNA's termination.
A resident with intact cognition reported feeling verbally abused by a CNA over several months, with staff failing to report the incidents to management. Despite multiple staff members witnessing aggressive behavior by the CNA, including refusal to provide care and derogatory comments, the facility's abuse policy requiring immediate reporting was not followed.
A resident with Alzheimer's and impaired cognitive function experienced a swollen knee, but the facility failed to document a timely pain assessment. Despite observations of swelling, discomfort, and bruising by an RN, no pain score or treatment plan was recorded. The DON confirmed that pain should be documented in progress notes, but this was not done, leading to a deficiency in professional standards of care.
A resident with severe cognitive impairment experienced a significant weight loss of 7.16% in one month, which was not identified or addressed by the facility. The care plan required monitoring for weight loss, but the DON acknowledged that the weight loss did not trigger in the facility notes and was missed by staff. The RD and DM were unaware of the issue due to a lack of alerts in the EHR system, and the facility lacked a policy on weight loss.
The facility failed to provide adequate staffing for dining assistance, as observed with two residents who had severely impaired cognitive skills and required assistance with eating. During an observation, both residents were left without assistance or food for extended periods. Staff interviews revealed that dining staffing was often inadequate, leading to delays in assisting residents. The DON was unaware of any reported concerns regarding dining staffing.
A facility failed to identify and document targeted behaviors and triggers for a resident prescribed olanzapine, leading to a deficiency in managing unnecessary medications. Despite the resident's diagnoses, the care plan lacked specific information justifying the antipsychotic use. Staff interviews revealed inconsistent documentation and care planning for the resident's behaviors, contributing to the deficiency.
Two medication errors were observed in the facility, involving residents with moderately impaired cognition. An LPN administered the wrong formulation of Senna to a resident, while an RN initially gave an incorrect dose of Lasix to another resident, later correcting it. The DON noted that staff should verify medications against the electronic health record, but this was not done, resulting in the errors.
A resident lost her dentures during a choking incident and experienced a delay in receiving dental care due to the facility's inability to find a provider accepting state benefits. The resident, who was cognitively intact and had a history of orthopedic and heart issues, was placed on a pureed diet, leading to weight loss. The facility lacked a policy on dentures, contributing to the delay in addressing the resident's dental needs.
A resident with severely impaired cognition did not receive a straw as required by their diet order, leading to a deficiency in care. Observations showed the resident using a regular cup, and staff interviews revealed a lack of awareness and communication about the resident's need for a straw. The facility's policy on adaptive self-feeding devices was not effectively implemented, resulting in the resident not receiving the necessary assistive devices.
Facility staff failed to follow infection control practices, leading to inappropriate antibiotic use. Antibiotics were often prescribed based on symptoms without test results, causing residents to continue treatment even when cultures were negative. The Antibiotic Stewardship Policy aims to promote appropriate use, but symptom-based prescribing persisted, contributing to the deficiency.
Failure to Perform Hand Hygiene Between Glove Changes During Wound and Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during personal care, wound care, and catheter-related care for one resident. The resident had intact cognition, was dependent for toileting hygiene, required substantial/maximal assistance with rolling, used an indwelling catheter, and was always incontinent of bowel. Diagnoses included obstructive uropathy, and the resident had a Stage IV sacrococcygeal pressure ulcer requiring daily wound treatments, as well as deep tissue pressure injuries and a moisture-related rash under both breasts and in the peri area. Physician orders directed daily cleansing and dressing of the coccyx wound with Vashe solution, calcium alginate, Triad paste, and foam dressing; application of antifungal cream to the underside of both breasts and peri-area; Triad paste to left glute/thigh wounds; and skin prep and dressing changes to the nephrostomy tube site. During an observed care episode, an RN placed wound care supplies on a barrier pad on the resident’s bed and repeatedly changed gloves between multiple care tasks without performing hand hygiene in between glove changes. The RN donned gloves, handled supplies, then changed gloves without hand hygiene before cleaning bowel from the resident’s buttocks. After removing those gloves, the RN again donned clean gloves without hand hygiene to cleanse and dress the coccyx pressure ulcer. The RN then removed gloves and, without hand hygiene, donned new gloves to apply Triad cream to the back of the resident’s right thigh, followed by additional glove removal and re-donning without hand hygiene to apply antifungal cream under the right breast and to the groin area. Finally, the RN removed gloves and donned another clean pair without hand hygiene to apply skin prep and dress the nephrostomy tube site. The facility’s hand hygiene policy stated that glove use does not replace hand hygiene and that staff must perform hand hygiene prior to donning and immediately after removing gloves.
Food Safety and Sanitation Deficiencies in Dietary Department
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations. In the walk-in refrigerator, a 5-pound container of tuna salad dated 4/6 and a 5-pound container of chicken salad dated 4/4 were found, both exceeding the facility's stated five-day limit for opened items. The ice machine in the kitchen had visible dust on its air filter, despite posted instructions to clean the filter twice a month, and this dust was observed on two separate occasions. Additionally, a styrofoam scoop was found stored in a clear plastic bin containing sugar. During food preparation, a dietary staff member with facial hair on the side of the face and above the lip was observed preparing pureed food without using a beard restraint. The Dietary Manager confirmed that opened food items should be labeled with the open date and discarded after five days, as per facility policy, but this was not followed for the items observed.
Failure to Issue Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, to two residents who were ending their Medicare Part A skilled services after meeting their therapy goals and returning to baseline independence. In both cases, the residents received the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), Form 10055, but not the NOMNC, which is mandated to inform beneficiaries that Medicare coverage is ending and to provide information on how to appeal the decision. Documentation reviews confirmed that the NOMNC was not issued, and staff indicated they were unaware that both forms were required. Interviews with the Social Worker revealed confusion regarding the correct forms to use, as she had only completed the SNF ABN and was not properly trained on the NOMNC process. The Social Worker began handling beneficiary notifications when the MDS Coordinator went on leave and acknowledged insufficient training from the previous Administrator. The Administrator was unaware of the error until it was brought to their attention, and the Nurse Consultant confirmed that the facility did not have a policy in place regarding beneficiary notifications.
Failure to Update Care Plan and Initiate PASRR Level II Specialized Services
Penalty
Summary
The facility failed to update the care plan and initiate specialized services for a resident as required by the PASRR Level II determination. Clinical record review and staff interviews revealed that the resident, who had severely impaired cognition, moderate intellectual disabilities, and an unspecified mood disorder, was prescribed antipsychotic, antianxiety, and anticonvulsant medications. The PASRR Level II outcome specified the need for ongoing psychiatric medication management by a psychiatrist or psychiatric ARNP, as well as facilitation of family involvement and supportive counseling from facility staff. However, the care plan lacked a focus area and interventions to address these specialized services. Interviews with facility staff, including the social worker, MDS coordinator, and DON, confirmed that the care plan had not been updated to reflect the PASRR Level II requirements. The social worker initially believed that psychiatric services were already in place, but later acknowledged that the resident had not received such services since admission. The DON also confirmed that the care plan should have been updated and that the facility had not addressed the PASRR Level II prior to the survey date. The facility did not have a policy related to PASRRs and relied on CMS regulations.
Failure to Address PTSD Triggers and Reasons in Care Plan
Penalty
Summary
The facility failed to adequately address the reason and trigger areas for a resident's diagnosis of post-traumatic stress disorder (PTSD) as part of the care planning process. Clinical record review showed that the resident had diagnoses including Parkinsonism, depression, and PTSD, with a care plan that only included general interventions such as reporting traumatic reactions to the provider or charge nurse. The care plan did not specify the resident's PTSD triggers or the underlying reason for the diagnosis, despite the resident being cognitively intact and on medication for PTSD. Interviews with facility staff, including the RN, MDS Coordinator, ADON, and DON, revealed a lack of knowledge regarding the resident's PTSD triggers and the specific reason for the diagnosis. Staff were unable to provide details about the resident's traumatic reactions or triggers, and the care plan was not individualized to address these aspects. Additionally, the facility did not have a policy related to care plans and relied on CMS regulations for guidance.
Failure to Ensure Timely Follow-Up for Constipation Management
Penalty
Summary
A deficiency was identified when a resident with a history of constipation, diabetes mellitus type 2, and end stage renal disease did not receive timely follow-up for constipation despite not having a bowel movement for multiple days. The resident was cognitively intact and had a care plan in place that included monitoring bowel movements every shift, administering medications as ordered, and reporting signs and symptoms of complications related to constipation. The resident was prescribed both scheduled and PRN medications for constipation, and was also receiving opioid pain medications, which can contribute to constipation. Record review showed several periods where the resident went multiple days without a documented bowel movement, specifically from 4/4 to 4/9, 4/13 to 4/17, and 4/19 to 4/22. During these periods, PRN medications were not consistently administered according to the facility's stated practice of intervening after three days without a bowel movement. For example, on some days when the resident had not had a bowel movement for several days, no PRN medication was given, and the resident reported not having a bowel movement in about a week. Staff interviews revealed inconsistent understanding and application of the bowel management protocol, with some staff stating that action should be taken after three days, while the DON confirmed there was no formal bowel protocol in place. The facility lacked a written policy or protocol for bowel management, and staff responses indicated variability in how constipation was addressed. The absence of a standardized approach led to delays in intervention and inconsistent administration of PRN medications, resulting in the resident experiencing prolonged periods without a bowel movement despite being at risk due to medical history and medication regimen.
Lack of Competency and Training in Wound VAC Application
Penalty
Summary
The facility failed to ensure that nursing staff providing wound care and applying a wound VAC possessed the necessary competencies and training. A resident with significant medical needs, including respiratory failure, ventilator dependence, diabetes, and a history of unstageable and stage 4 pressure wounds, was dependent on staff for all care. The care plan and treatment administration record required specific wound care interventions, including the use of a wound VAC. However, observations and staff interviews revealed that the LPN responsible for wound care and wound VAC application had not received formal training in these areas and relied on self-directed learning. Further interviews with facility staff, including another LPN, the DON, and the Administrator, confirmed that there was no designated, formally trained wound care nurse, nor was there a facility policy for wound care or wound VAC use. The staff member identified as the wound care nurse performed all wound measurements and VAC changes without formal training, and the facility lacked structured guidance or protocols for these procedures.
Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
The facility failed to ensure that insulin was administered according to physician orders for two residents with diabetes. For one resident, the physician order specified that insulin should be held if blood sugar was less than 150, yet there were eighteen documented instances where insulin was administered despite blood sugar readings below this threshold. The resident's care plan indicated diabetes management with medication as ordered, and the MARs showed repeated administration of insulin when blood sugar was less than 150. Staff interviews revealed that nursing staff did not consistently follow the parameters set by the physician order, with one RN stating disbelief in the necessity of the parameters and another indicating that administration was based on dietary intake rather than the specified blood sugar threshold. For the second resident, the physician order also required insulin to be held if blood sugar was less than 150, but the MARs documented multiple instances over several months where insulin was given despite blood sugar readings below this level. Staff interviews indicated a lack of awareness or understanding of the parameters for insulin administration, with some staff believing that only certain residents had such parameters. The Director of Nursing and Administrator confirmed that there was no facility policy addressing medication administration in these circumstances. Both residents had documented cognitive impairments and required insulin injections as part of their diabetes management.
Improper Catheter Management Leads to Severe Complications
Penalty
Summary
The facility failed to properly evaluate and manage the placement of a urinary catheter for a resident, leading to significant complications. After a routine catheter change, the resident experienced little to no urine output and bloody urine for two days. Despite these symptoms, the facility did not take immediate action, and the resident continued to have bloody urine for an additional two days before being sent to the hospital. Upon hospital evaluation, it was discovered that the catheter balloon was incorrectly placed in the urethra, causing trauma and resulting in a urinary tract infection (UTI). The resident involved had a history of benign prostatic hyperplasia (BPH), heart failure, and diabetes mellitus, and was dependent on staff for toileting hygiene. The resident's care plan included monitoring for signs and symptoms of UTI and ensuring proper catheter care. However, the facility's failure to respond promptly to the resident's symptoms of hematuria and decreased urine output indicated a lapse in following the care plan and physician orders. The hospital findings revealed that the resident had emphysematous cystitis, acute kidney injury, and right lower lobe pneumonia, all of which were exacerbated by the improper catheter placement. The resident's condition deteriorated over several days, with symptoms including abdominal pain, decreased appetite, and general weakness. The facility's inaction in addressing the resident's symptoms in a timely manner contributed to the severity of the resident's condition upon hospital admission.
Inadequate Food Temperature Management
Penalty
Summary
The facility failed to ensure that food was served at adequate temperatures, as observed during a survey. Staff B, a dietary staff member, recorded food temperatures that were below the facility's policy requirements. For instance, the breaded pork chop was recorded at 142 degrees Fahrenheit initially and later at 139.5 degrees Fahrenheit, while the ground pork was at 127 degrees Fahrenheit. These temperatures were below the facility's policy, which mandates that hot foods be served at a minimum of 135 degrees Fahrenheit, preferably at 160 degrees Fahrenheit or higher. Additionally, the pureed pork was initially recorded at 165 degrees Fahrenheit after being placed on the steam table, which was compliant, but other items like the fish fillet and green beans were served at lower temperatures. Resident #29, who was cognitively intact and required assistance with eating, expressed dissatisfaction with the food, citing issues with taste, temperature, and appearance. The resident specifically mentioned that the fish served was not hot. Interviews with the Dietary Manager and Staff B revealed inconsistencies in their understanding of the required food temperatures, with Staff B incorrectly stating that ground meat should be served at 175 to 180 degrees Fahrenheit. The Dietary Manager also confirmed that green beans were served at 121 degrees Fahrenheit, which was below the expected temperature. The Interim Administrator expected food to be served at least 165 degrees Fahrenheit, highlighting a discrepancy between the facility's policy and actual practice.
Inadequate Infection Control During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident. During an observation, a Licensed Practical Nurse (LPN) was seen handling medications, including Levitracetam, Pregabalin, and a stock medication of Calcium with Vitamin D3, with bare hands while preparing them for administration. The LPN touched the medications directly with their hands when placing them into a medication cup and when dispensing from a medication bottle cap. The facility's Infection Preventionist acknowledged that handling medications with bare hands was inappropriate and mentioned a procedure for replacing dropped pills. The Director of Nursing (DON) also stated that dropped pills should be replaced. However, the facility's Medication Administration policy, effective since 2019, did not address this specific concern.
Resident Dignity Compromised by CNA's Inappropriate Conduct
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner, specifically in the case of a resident who was subjected to inappropriate behavior by a Certified Nursing Assistant (CNA), identified as Staff H. The resident, who had intact cognition and was dependent on staff for toileting hygiene, reported that Staff H spoke to her in an aggressive and accusatory manner regarding a personal relationship with another resident. Staff H made derogatory comments about the resident's incontinence and refused to answer her call light, leaving the resident feeling intimidated and verbally abused. The investigation revealed that Staff H had a history of disagreements with the resident and had been reported by other staff members for refusing to provide care and for turning off the resident's call light. Staff H admitted to having a disagreement with the resident and acknowledged making comments about the resident's personal life. Other staff members corroborated the resident's claims, noting that Staff H had been abrasive and had refused to assist the resident, which led to the resident feeling unsafe and uncomfortable. The facility's investigation concluded that the allegations of abuse were substantiated, leading to the termination of Staff H. The investigation found that the abuse was isolated to this employee, and no root cause analysis was deemed necessary. The facility's leadership, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), acknowledged that Staff H's behavior was inappropriate and that the situation should have been addressed sooner.
Failure to Report and Address Alleged Verbal Abuse
Penalty
Summary
The facility failed to adhere to its abuse policy when staff did not notify management of potential abuse concerns involving a resident. Resident #50, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status exam, reported feeling verbally abused by a CNA, Staff H, over a period of 2 to 3 months. The resident described an incident where Staff H made accusatory remarks about her relationship with another peer, which was particularly distressing given the recent death of her husband. Multiple staff members, including CNAs and an RN, were aware of the ongoing issues between Staff H and Resident #50. Staff K, RN, noted that the resident did not want Staff H in her room, leading to a temporary switch of residents between Staff H and another CNA. However, the situation persisted, with Staff H reportedly refusing to provide care to Resident #50 and turning off her call light while she was on the bedpan. Other staff members, such as Staff G and Staff I, witnessed Staff H's aggressive behavior towards residents, including yelling and making derogatory comments. Despite these observations, the staff did not report the incidents to management in a timely manner. The Director of Nursing expressed a desire for earlier reporting and confirmed that staff had been educated on the importance of reporting abuse. The facility's abuse policy required immediate reporting of any allegations of abuse to the charge nurse, who was then responsible for informing the Administrator or designated representative. This protocol was not followed, contributing to the deficiency identified in the report.
Failure to Document Pain Assessment for Resident with Swollen Knee
Penalty
Summary
The facility failed to ensure timely documented assessment of pain and symptoms for a resident with impaired cognitive function and Alzheimer's disease. The resident was reported to have a swollen right knee without redness or warmth, and the ARNP was notified, but no new orders were given. The resident's daughter, who is the Power of Attorney, was also informed. Over the weekend, the resident's condition included swelling, discomfort, and bruising, which was noted by Staff K, a Registered Nurse. Despite these observations, there was no documented pain assessment or treatment plan initiated. The Director of Nursing (DON) indicated that pain should be documented in the progress notes and treated if present, but there was no evidence of a pain score or effectiveness of pain medication being charted. The RN job description requires comprehensive assessments to be performed and documented, which was not adhered to in this case. The lack of timely and thorough documentation and assessment of the resident's pain and symptoms led to a deficiency in meeting professional standards of quality care.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional standards, resulting in a significant weight loss for one resident. Resident #31, who has severe cognitive impairment and requires supervision with eating, experienced a 7.16% weight loss in one month. The care plan for the resident included monitoring for signs of malnutrition and significant weight loss, but the facility did not identify or address the weight loss in a timely manner. The Director of Nursing (DON) acknowledged that the weight loss did not trigger in the facility notes and was not caught by staff, despite the resident's weight loss exceeding the threshold for concern. The Registered Dietitian (RD) and Dietary Manager (DM) were also unaware of the weight loss issue, as it was not flagged in the electronic health record (EHR) system. The RD, who works mostly offsite, had not met the resident and relied on the EHR system to trigger significant weight loss alerts. The DM mentioned that the resident's weight loss might have been discussed in a previous meeting, but there was no documentation to confirm this. The DON later realized that the system had triggered the weight loss alert, but it was inadvertently deleted. The facility lacked a policy regarding weight loss, contributing to the oversight.
Inadequate Staffing for Dining Assistance
Penalty
Summary
The facility failed to provide adequate staffing to assist residents with dining, as observed in the case of two residents with severely impaired cognitive skills. Resident #20 required partial/moderate assistance for eating, while Resident #40 required supervision or touching assistance. During an observation in the dining room, both residents were left without assistance or food for extended periods. Staff N, a dietary staff member, was observed providing minimal assistance, such as offering drinks, but did not ensure that the residents received their meals in a timely manner. Resident #40 requested chocolate milk, but was told to wait, and both residents were observed without food or drink for significant periods. Interviews with staff members revealed that staffing during dining times was inadequate, with CNAs expressing that it was overwhelming and difficult to attend to all residents. Staff G mentioned that they were often told to place residents in the activity room with the television on if they could not be fed promptly. Staff E and Staff F also acknowledged that there were times when staffing was insufficient, leading to delays in assisting residents with dining. The Director of Nursing was unaware of any reported concerns regarding dining staffing, despite the evident issues observed and reported by the staff.
Deficiency in Identifying Triggers for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that targeted behaviors and triggers were identified for the antipsychotic medication olanzapine for a resident, leading to a deficiency in managing unnecessary medications. The resident, who had a BIMS score indicating intact cognition, was diagnosed with unspecified dementia, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and other mood disorders. Despite these diagnoses, the care plan lacked specific information identifying triggers and behaviors that would justify the use of antipsychotic medications. Interviews with staff revealed that while the resident occasionally displayed behaviors such as getting upset and yelling at staff, these were not consistently documented or addressed in the care plan. The facility's policy on antipsychotics, updated in January, did not include documentation requirements for addressing antipsychotic use in the care plan. Staff interviews indicated a lack of clarity and consistency in documenting and addressing the resident's behaviors and triggers. The MDS Coordinator and DON acknowledged that behaviors were only charted when displayed or when there were medication changes, and interventions were not consistently included in the care plan. This oversight in care planning and documentation contributed to the deficiency identified by the surveyors.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors observed during the administration process for two residents. Resident #41, who has moderately impaired cognition, was prescribed Senna Oral Tablet 8.6 mg to be taken as two tablets every other day. However, on the day of observation, an LPN administered Senna Plus, which contains both Senna and Docusate Sodium, instead of the prescribed medication. Similarly, Resident #36, also with moderately impaired cognition, was prescribed Furosemide (Lasix) 40 mg to be taken twice daily for three days and then once daily. During the medication administration, an RN initially gave the resident Lasix 20 mg and later realized the error, subsequently administering an additional dose. The Director of Nursing explained that staff should verify medications by comparing the pharmacy label with the electronic health record, but this protocol was not followed, leading to the errors.
Failure to Provide Timely Dental Care After Denture Loss
Penalty
Summary
The facility failed to ensure timely dental care for a resident who lost her dentures during a choking incident. The resident, who was cognitively intact and had a history of non-surgical orthopedic/musculoskeletal issues and chronic diastolic heart failure, choked on an onion and removed her dentures, which were subsequently lost. Despite efforts to locate the dentures, they were not found, and the resident was placed on a pureed diet, leading to weight loss. The care plan was not updated to address the loss of dentures or the need for replacement. Interviews with staff revealed that the facility had difficulty finding a dental provider who accepted state benefits, delaying the replacement of the dentures. The resident had been seen by a new dental agency starting in March 2024, but prior to this, there was no on-site dental care available. The facility lacked a policy on dentures, contributing to the delay in addressing the resident's dental needs. The resident's diet was eventually changed back to a regular texture, and she regained some weight, but the deficiency in timely dental care remained unaddressed for an extended period.
Failure to Provide Assistive Dining Devices
Penalty
Summary
The facility failed to provide assistive devices for eating, specifically a straw, as per the diet order for a resident with severely impaired cognition. The resident's care plan and physician order indicated the need for a straw to assist with fluid intake, yet observations on multiple occasions revealed the resident was using a regular cup without a straw. Interviews with staff, including the Registered Dietician, Certified Nursing Assistant, and Dietary Manager, indicated a lack of awareness and communication regarding the resident's need for a straw, as outlined in the diet order. The facility's policy on adaptive self-feeding devices requires that such needs be identified and evaluated by nursing, dietary, and therapies. However, there was a disconnect in communication and implementation of this policy, as evidenced by the staff's uncertainty about the resident's requirements and the absence of straws on the menu tickets or in the kitchen. The Director of Nursing acknowledged the lack of clarity on how this information should be communicated, highlighting a deficiency in ensuring the resident received the necessary assistive devices for dining.
Inappropriate Antibiotic Use Due to Symptom-Based Prescribing
Penalty
Summary
The facility staff failed to adhere to infection control practices aimed at reducing unnecessary or inappropriate antibiotic use. The facility's Antibiotic Report for January, April, and May 2024 documented instances of inappropriate antibiotic starts, with ten residents affected in January, eight in April, and five in May. The Infection Preventionist (IP) indicated that antibiotics were often prescribed based on symptoms without waiting for test results, leading to residents continuing antibiotic treatment for the full duration of the prescription even when cultures returned negative. The facility's Antibiotic Stewardship Policy, dated November 28, 2017, outlines the goal of promoting appropriate antibiotic use to maximize treatment outcomes and minimize unintended consequences. Despite this policy, the practice of prescribing antibiotics without confirmed test results contributed to the deficiency. The IP tracks all antibiotics prescribed, including orders, diagnostic testing, and results, but the practice of prescribing based on symptoms persisted, contributing to the inappropriate use of antibiotics.
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A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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